CRITICAL INCIDENT REPORT FORM

Incident #
Date of Report Date of Incident/Death:

Date of Discovery of Incident/Death: Time of Incident/Death:

State Hospital reporting:

Community Provider reporting:

If reporting provider is a subcontractor, who is primary contractor?

Contact Person: Contact Person phone #:

MHDDAD Region #: Person Completing Report:

Name of site and/or specific location where incident/death occurred (i.e.: Unit name/number, name of PCH, etc):

Check appropriate box

(please specify):

Consumer(s) Information*

Name DOB Age at Time of Incident Sex

Address City State GA Zip County

Medicaid Waiver? CID # SS# Race

Admission Date Disability: Check box if consumer directed services

List agency services in which consumer is enrolled:

Extent of Injury:

Brief description of injury:

Name DOB Age at Time of Incident Sex

Address City State GA Zip County

Medicaid Waiver? CID # SS#: Race

Admission Date Disability: Check box if consumer directed services

List agency services in which consumer is enrolled:

Extent of Injury:

Brief description of injury:

 CRITICAL INCIDENT REPORT FORM
Type of Incident
Category I (check all that apply) Check here if incident is high visibility
(please complete death section)

Category II (check all that apply) Check here if incident is high visibility

Brief description of incident

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Witnesses to Incident

Name Contact #

Name Contact #

Name Contact #

Name Contact #

Notifications
Agency Name Date/time Method of Notification

Deaths (if applicable)

How was death discovered?

Date of last contact with consumer: Reason for contact:

Was death expected? Was death an accident?

Possible suicide? Possible Homicide?

Presence of Significant disease processes/factors in death (check all that apply)

Has autopsy been ordered If not state reason:

Cause of death, when known:

Were there unusual circumstances surrounding death? If yes, please describe below

Administrator’s Review for all critical incidents

State Hospital/Community provider staff/title:
Date:

By checking this box, I attest that the above entry for State hospital/community provider staff/title verifies my review of the
incident.